Findings

Daniel Terziski was born with a very serious heart defect. That defect led to his death following an operation intended to be the first step in a long-term plan for amelioration of the defect. But the procedure was a high-risk one. Many children in Canada, with the same defect as Daniel had, died following surgery. The questions that arose from this case included the decision to perform the procedure here in Winnipeg, as well as the manner in which the case itself was handled.

The issues are:

Should Daniel's condition have been diagnosed earlier?

Was Daniel's family provided with sufficient information to allow them to give informed consent to the procedure?

Was Daniel healthy enough to undergo an operation?

Should the HSC team have attempted the operation or should Daniel have been referred out of province?

Should there have been better planning for this procedure?

Did the length of surgery contribute to Daniel's death?

Was there appropriate post-operative care?

What was the cause of death and was it preventable?

Should Daniel's condition have been diagnosed earlier?

Finding

Two of the consulting witnesses who appeared before this Inquest indicated that Daniel's heart defects should have been identified before his birth. In addition, his mother sought medical attention several times before Daniel was properly diagnosed. While Dr. Walter Duncan indicated that the type of defect that Daniel suffered from is difficult to detect, early detection might well have led to more effective treatment of Daniel. The evidence suggests that Daniel's condition should have been detected earlier than it was.

Was Daniel's family provided with sufficient information to allow them to give informed consent to the procedure?

The evidence suggests that the family was not encouraged to seek a second opinion. They were offered the option of sending their child out of province. However, when they raised the prospect of bringing a surgeon to Manitoba, it was made clear to them that this was unnecessary, since there was nothing available outside the province that was not available in Manitoba. This amounted to a form of pressure to have the procedure carried out in Manitoba. The assurances given to the Terziskis about the competence of the Winnipeg team must be considered in light of the comments from witnesses. Both Duncan and Cornel said that it might not have been wise for the Winnipeg team to undertake a Norwood at that point in its history, and Soder commented on the role that surgical issues played in Daniel's death.

Finding

As in other cases discussed above, Daniel's parents were not fully informed as to the fact that this was Odim's first Norwood, either without supervision or with expert assistance. Nor were Daniel's parents informed about the recent deaths of other patients in the program. This fact was of significance by this point, since many of the people involved in the program were clearly concerned about its mortality and morbidity rates. This evidence tends to suggest that Daniel's parents were not provided with sufficient information to allow them to give informed consent to the procedure.

Was Daniel healthy enough to undergo an operation?

Finding

As noted above, there was in this case, as there had been in several other cases, concern on the part of the consulting witnesses that Daniel was taken to surgery with an infection. There appears to be some evidence to validate that concern. The concerns about infection with respect to the Caribou case and the Goyal case have equal application here.

Should the HSC team have attempted the operation or should Daniel have been referred out of province?

Finding

In the wake of the results in the Goyal, Caribou and Ulimaumi cases, and given Odim's lack of experience (coupled with the overall lack of planning), it was unwise to undertake this operation in Winnipeg.

Should there have been better planning for this procedure?

Finding

The evidence suggests that there was not enough planning for either the operation or the post-operative care.

Did the length of surgery contribute to Daniel's death?

Cornel, Duncan, Hudson and Soder all noted that the operation was lengthy and that this length could have compromised Daniel's heart. In their joint report, Cornel and Duncan wrote:

There appear to be some questionable surgical management issues related primarily to the duration of bypass. We once again question the appropriateness of an inexperienced surgical team performing Norwood procedures. (Exhibit 354, page 6)

Soder indicated in his report for this Inquest that:

[T]he skill and dexterity of the surgeon performing these operations were insufficient for the challenge of successfully repairing infant hearts with complex malformations. Surgical factors were the prime determinants of fatal outcome in 9 of the 12 deaths. (Boldface in original) (Exhibit 345, page 8)

Finding

The case of Daniel Terziski was one of the nine that Soder identified in which surgical factors were a prime determinant in a fatal outcome. In particular, he identified the failed first repair and prolonged circulatory arrest time as major surgical factors and the prolonged bypass time as a minor factor. The evidence suggests that the length of surgery contributed to Daniel's death.

Was there appropriate post-operative care?

Findings

The evidence suggests that the neonatal intensive care unit was not properly prepared to deal with Daniel Terziski. Although staff in the NICU sought information from Odim before the operation, according to testimony, they only received vague responses. The fact that the neonatologist was not present when Daniel arrived from the OR indicates a breakdown in communication. It is also disturbing that the resident, and later Odim and Giddins, briefly left Daniel without a doctor being present at his bedside. In his written report Cornel noted that Daniel should have received more monitoring of oxygen and carbon dioxide (blood gas analysis) and of the amount of potassium in his blood.

Cornel wrote that the "wisdom of managing complex open heart patients at two sites in the same small institution is questionable." (Exhibit 353, page 32) In his testimony, Cornel expanded upon this point, which referred to the fact that in Winnipeg, both the NICU and the PICU managed open-heart cases:

It's not just in dealing with Norwoods, I would really need to know what their experience in dealing with post-operative open heart patients was. We do about 50 babies, or less from neonates-it would be less than that. And so for neonates, to accumulate the experience in post-operative management, for the neonatal intensive care unit to accumulate the post-operative management skills would take a long time. Especially with nursing shifts, you don't get the same nurses, it really spreads out the experience too much I think. (Evidence, pages 44,817-44,818)

In the coming months Odim did seek to have all open-heart cases managed by the PICU post-operatively.

What was the cause of death and was it preventable?

Because there was no autopsy, it is difficult to state with certainty the cause of death in Daniel's case. It is clear that the operation failed to alleviate Daniel's condition. It also appears the operation exacerbated the problems that Daniel was experiencing. This was due at least in part to the length of the operation. Daniel's heart defect meant that there was torrential blood flow through his lungs, severely taxing his single (left) ventricle. As a result, he started to develop heart failure, which led to a decrease in oxygen saturation and damage to the heart muscle itself. Daniel then underwent a prolonged operation, with a very long circulatory arrest time, which led to more damage to his already compromised heart. This further reduced his heart's ability to pump blood and the heart failed. The length of the TCA would have also caused some neurological damage to Daniel. With the heart failure came a resultant drop in blood oxygen, and a consequent decrease in oxygen delivered to the heart muscle. As Daniel's heart struggled to pump, his blood pressure decreased. The heart rhythm then became abnormal and he suffered a cardiac arrest.

Finding

Given the fact that there was no autopsy and that Norwoods are a high-risk operation, it is not possible to provide a clear-cut answer as to whether or not this death was preventable. It is clear that the chances of preventing this death would have been increased if the child had been referred out of province.